23691•
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
PERh9TNO.
Building Address: e,2
23691
hone:
—ZG{ 3
CITY OF CUPERTINOBUILDING DIVISION
APPLICATION / PERMIT BUDINGELECTRCALPLMBING-MECHAMCAL
A A A
n✓ ctor ear3dN
CATEGORY
CONTROL If
Architect/En fie r. Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add.
PERhIITISSUANCE
1:1 11 El
CONTRACTOR'S DECLARATION
I bereby affirm that l am licensed under provisions of Chapter 9(commenc
ton7000)of DiviMm3ofthe Businessand PmfemionsCodg dm
license is in full9and effect.
Llcnnsc ��33%s 7�_Llc.a 35
APPLIANCES -RESIDENTIAL
]OB DESCRIPTION'ngwlthSe
' 1,
Gl4r ia`
PANELS
Date�[2g(g�Conlractor On /'f„�
'''�� ����ARCHITECTS DECLARATION J
I understand my plans shall be used as public records
.
ZOi'tOW AMPS
JOVERIOOOAMPS
SQ. FT. FLOOR AREA
Licensed Professional
E D
SIGNS ELECTRICAL1
OWNER -BUILDER DECLARATION
I hereby afflrmlhat l am exempt fromthe Contractors License law for the
following reamr.(Section 7(Itt.S, Business and Professions Code: Any city or
countywhich requires a permit m m
construct, alter, Improve, deolish,or repair
any structure prlorto its hasuance,aleo requitestheapplicant for such permit to
file a signed statement that he is B¢nsed pursuant to the provisions of the
Conteactorb License law (Chapter 9 (comma ncing with Section 7000) of Divi-
3 ofthe Businessand Professions Code) orthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any Nb
appucant fora pertubjects the applicant to a civil peoaltyof more ore than
five hundred dollar (5.500).
❑ 1, as owner of the property, or my employees with wages as their sole
SPECIALCItCUIT/MLSC
amp
L I N
�vj 2
J/
PTEIVI.MEfER OR POLE INST.
POWER DEVICES D T
SWIMMING POOL ELECTRICsion
OUTLETS-SWITCHES-FIXNRES
VALUATION
P e
NEW RESIDENTIAL ELECTR c"Q'Fr.
STOW FS
TYPE CONSTRUCTION
compensation, willdothe work and the structure isnot intended or offered for
sale (Sec. 7044, Bus4ssi and Professions Code: The Contractors License Law
does not apply to an owner of property who Wilds or improve thereon,and
who don such work himself orthreugh his own employees, provided that each
OCC.GROUIs
RES.UNUS
improvements are not Intended oroffered for sale. If, however, the Wilding or
improvement 6sold within oneyearofcomplelien, the owner -builder will have
t)AUmen of proving that M did not build or improve for purpose of sale.).
LJ I. as owner of the property, am exclusively contracting with Retread!PERMIT
contractors to contract the project (Sec. 7044, Business and Professions Code:
TOTAL:
QTY. PLUMBING PERMIT FEE
ISSUANCE '
.
FLOO ,NNE
APN
no Contr ctore Limnae Law does not apply to an owner of property who
Wilds or Improve thereon, and who contacts for such projects with a
�gIlt(ador(s)Bme pursuant to the Contractor's Llceme Law.
ec
LJ I am exempt under SB k P C for this reawn
ALTER -DRAIN kVENT-WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
ouTsi DE Pi �rq
Owner Date
WORIQ,IAN COMPENSATION DECLARATION -
1 hereby affirm that I have a rtlRow
❑ m of consent to self -In re, or
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEIPT X
E.IX.ES.D�s
PER
SQi00L TAX Y_
_ Nte
certificate ofWorkeni Compensation lrsuranceora certified copy thereof(See
Moe Lab C.) G•
Pollry X
AECQ[PI' X
GAS EA.SYST0M1 INC.4OITTLITI'S
PARK FTI: Y N
RECEIPT X
Com any
[CertiAed copyis herebyfiled ishecl.
QBdrtilted copy la filed with the hely inspection division.
GAS EA. SYSTG/-OVER4(EA)
GREASE/INDUSIRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PI -CHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(1'hlauctlan neednot M completed Nthe permit V (or One hundred dollare
PAID
Date Recel t#
SEWER-SANITARY
(stlo)oneaa.)
seesubjecissued,
]certify thatln the person
um an tmanner for wto become
I shall not employ any person f any manner ao u to become abject to the
Workcrs'Compensation lawn of Gll(ornfa. Date
Applicant
NOTICE TO APPLICANT: ILaher making this Certl(Itate of Exemption, you
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
DatC RCeel t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ7T.
shwld become subject to the Workers' Campensatlon provlalom of tW Labor
Code, you most forthwith comply with such provedom orthis permit shall be
deemed revoked.
TOTAL:
-BUILDING FEEr'a
TOTAL:
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them ea a corohuction lending agency for the perform-
ante of the work for which this permit is Weed (Sec 3097, Civ. C3
SEISMIC FEE
ELECTRIC FEE
Lender'.Name
Lender's Adds,,,
I rent ify that I have read this application and arae that the above Information
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
ecorred.I agree to comply withal) dtyand county ordinances and state laws
relating to Wilding comtmction, and hereby authorize reprearentatives of this
city to enter upon the abovcmentioud property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabNties,judgments, cortsand expenses which may In anywayamme
against a aid City a consequenso)t granting Wth permit.
PERMIT ISSUANCE
ALTERORADDTOMFCH.
AIR HANDLING UNIT (TO 10,000 CFM)
FEESPAID-
Date Receipt#
SUBTOTAL•
AIR HANDLING UNIT(OVER 10,000CE.M)
CONSTRUCTION TAX
/
a2
Signstureof ApplicamlComout D e
HAlARDOUS ATERIALS SCLOSURE
Well theappllcantorforam building occupant store or handle harardous
materials, defined by the Cupemno Municipal Code, Chapter 9.12,and the
He❑alt Y and Safety Code, Sedioon 25537(a)?
HAUST I TOOD(W/DUCT)
CONSTRUCTION TAX PAID:
Date Recei t#
TOTA
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENIIL.ATION FAN(SINGLE RESID)
ISSUANCE DATE
p� p'
P A
Q as
JUL 2 L
Will the applicant or future Wilding occupant use equipment or devices
which emit havardom air mnlarn antsas defined by the Bay Ares Air
Quality Management District?
Yea F� No
have read the has r us materials requirements under Chapter6.95 of
the California Health k SafetyCode,Sections 25505, 25533 and 75534. I
understand that if thebuilding does not currently have atenant, that it u my
responsibility to notify the occupant of the requirement, which must be met
ROLLER -COMP DHPOR 100,000 BW
BOILER -COMP (OVER 100,000 RTL)
N RESIDENTIAL MECH. SQ.FT
prior to issuance of a Certificate of Occupancy.\��
re WY r•,tIIYV
ISSUED BY."- c F -i
Owneror authonnd agent Date
TOTAL:
OFFICE COPY